1.

Are you :

Male

Female

2.	What age group do you belong to?
	Under 18		18 - 24		25 - 34
	35 - 45		46 - 60		Over 60

3.	Which of the following best describes your circumstances? (Please tick any that apply to you)
	Student		Working Full time		Lone parent
	Unemployed		Full time parent		Retired
	Working Part time		Person with disabilities

4.	Do you have any of the following disabilities ? (Please tick any that apply to you)
	A physical or limited mobility impairment		A hearing impairment		Mental health issues
	A visual impairment		A learning difficulty		Reading or writing problems

5.	How long have you been claiming Housing Benefit/Council Tax Benefit?
	Less than 6 months		1 - 2 years		5 - 10 years		Not sure
	6 months to 1 year		2 - 5 years		More than 10 years

6.

Do you know you need to report any change in your circumstances?

Yes

No

7.

Do you know that if your household income changes, your benefit may go up or down?

Yes

No

	Why do you believe this?

8.

Do you understand why this happens?

Yes

No

	Please give me further details

9.

Do you know what will happen if you do not tell us of a change in your circumstances?

Yes

No

	Please give further details

10.

Have you read the examples on the award letter of what changes to tell us about?

Yes

No

	If no, is there a reason why you have not?

11.

From our award letter is it clear: What changes you have to tell us about?

Yes

No

Why you have to tell us?

Yes

No

When you have to tell us?

Yes

No

Whom to tell?

Yes

No

What to do when your circumstances change?

Yes

No

	(If you have said no to any of the questions, please tell us what you do not understand)

12.

Are you aware you need to tell us changes even if you have told another organisation like Department for Work and Pensions, Revenues and Customs, Pension Service?

Yes

No

	If no, is there a reason why not?

13.

Do you know  the time limit to tell us when your circumstances change?

Yes

No

14.	Please tell us the time limit

15.	How would you tell us about a change in your circumstances?

16.	How would you prefer to contact us:
	Visit Whitfield Ofices		Send a letter		Complete a change of circumstances form
	Visit Area Offices		E-Mail		Other (please state)
	Telephone		Internet

17.	Is there anything we can do to help you in reporting changes to avoid overpayment or loss of benefit?

	Your Full Name

	Your Address and postcode

	Telephone number

	E-Mail address

To help make sure our services are reaching the right people, we would appreciate it if you would answer the following questions about yourself.

	What is your partnership status?
	Single		Living with partner		Divorced
	Married / Civil partner		Separated		Widow / Widower

	To help us address issues different sections of our community may be experiencing, we would appreciate it if you would tell us which faith group, if any, you belong to.   This question is entirely voluntary.

We would also appreciate it if you would answer the following question about your sexual orientation.   This is entirely voluntary and will not be shared with anyone.

	Are you?
	Heterosexual		Gay Woman
	Bisexual		Other
	Gay Man		Prefer not to say

Dover District Council operates a policy of equality in all aspects of the organisation's work.   To assist us in monitoring this policy please tick an ethnic group

	White
	British		Irish		Other white European		Other white non-European

	Mixed
	White and Black Caribbean		White and Black African		White and Black Asian		Other mixed

	Asian and Asian British
	Indian		Pakistani		Bangladeshi		Other Asian

	Black or Black British
	Caribbean		African		Other Black race

	Chinese or other ethnic group
	Chinese		Other

	Any nationality not mentioned above

Thank you for taking the time to complete this form